The prognostic significance of race and survival from prostate cancer based on patients irradiated on Radiation Therapy Oncology Group protocols (1976-1985)

Optimal timing of radiotherapy in high risk prostate cancer: Do missed days matter?

Introduction

High-risk prostate cancer is associated with poorer overall survival (OS) and biochemical control compared to more favorable risk groups. External beam radiation therapy (EBRT) is widely used; however, outcomes data are limited with respect to time elapsed between diagnosis and initiation of EBRT.

Methods

The National Cancer Database was queried from 2004 to 2015 for patients diagnosed with high-risk adenocarcinoma of the prostate who received androgen deprivation therapy (ADT) and definitive EBRT. Logistic regression was utilized to determine covariates associated with missing EBRT treatments. OS was analyzed using multivariate cox proportional hazards models and propensity score matching.

Results

9,610 patients met inclusion criteria with median follow-up of 40.6 months and median age of 72 years. Median PSA was 8.7 and median EBRT dose was 78 Gy. ADT was initiated at a median of 36 days and EBRT at a median of 63 days post-diagnosis. Median number of prolonged treatment days was 2.2. Black race (OR: 1.40; p < 0.01), treatment at a community clinic (OR: 1.32; p < 0.01), and living in an urban/densely populated area were associated with prolonged treatment. Time elapsed between ADT and EBRT > 74 days (HR: 1.20; p = 0.01) and prolonged treatment>3 days of EBRT (HR: 1.26; p = 0.005) were associated with an increased hazard of death. The 5-year OS was 79.6% and 82.9% for patients with prolonged treatment of 3 days or more of EBRT and those missing 3 days or less, respectively (p = 0.0006).

Conclusion

In this hypothesis-generating study, prolonged treatment delays and missing three or more EBRT treatments was associated with poorer OS in patients with high-risk adenocarcinoma of the prostate.

Race Does Not Affect Tumor Control, Adverse Effects, or Quality of Life after Proton Therapy

Purpose

To compare 5-year biochemical control, toxicity, and patient-reported quality of life (QOL) outcomes for African American and White patients treated with proton therapy (PT) for prostate cancer.

Materials and Methods

We reviewed the medical records of 1,066 men with clinically localized prostate cancer. Patients were treated with definitive PT between 2006 and 2010. Patients received a median radiation dose of 78 Gy (RBE) with conventional fractionation (1.8- 2 Gy [RBE] per fraction). Sixty-eight (6.4%) men self-identified as African American and 998 (93.6%) self-identified as White. Five-year rates of biochemical control, grade 3 genitourinary and gastrointestinal toxicity, and patient-reported QOL are reported and compared between African American and White patients.

Results

Median biochemical follow-up was 5.0 years for both African American and White patients. Median follow-up for toxicity was 5.0 and 5.2 years, respectively. On multivariate analysis, race was not a significant predictor for 5-year freedom from biochemical failure (HR 0.8, p=0.55). No significant association was found between race and grade 3 genitourinary toxicity on multivariate analysis at 5 years (HR 2.5, p=0.10). Patient-reported QOL using median EPIC bowel, urinary incontinence, and irritative summaries scores were not significantly different between the groups. African Americans had higher median sexual summary scores at 2 years than White patients (75 vs. 54, p=0.01) but by 5+ years, the sexual summary scores were no longer significantly different (63 vs. 53, p=0.35).

Conclusion

With a median follow-up of 5 years, there were no racial disparities in biochemical control, grade 3 toxicity, or patient-reported QOL after PT for prostate cancer.

Curative brachytherapy for prostate cancer in African-Caribbean patients: A retrospective analysis of 370 consecutive cases

PURPOSE

Prostate cancer is the most frequent malignancy in African-Caribbean men, a population sharing common genetic traits with African-American (AA) but presenting also genomic and epidemiologic specificities. Despite socioeconomic disparities with French mainland, all patients were treated within the French state-financed equal-access health care system. In this study, we report biochemical outcomes of patients treated by brachytherapy in our department from 2005 to 2014 in an African-Caribbean population.

METHODS AND MATERIALS

Three hundred seventy consecutive patients receiving 125I brachytherapy as a curative treatment for early-stage (localized) disease between 2005 and 2014 were recorded. Selected patients presented with low-risk disease: initial prostate-specific antigen (PSA) <10 ng/mL, clinical stage ≤ T2c, and Gleason score <7. Patients with intermediate risk of recurrence were also included on a case-to-case basis with prostate-specific antigen <15 or Gleason score 7 (3 + 4). Biochemical failure free-survival was defined according to the American Society for Radiation Oncology nadir+2 definition.

RESULTS

The 3-year and 5-year biochemical failure free-survival for the entire cohort were 98.3% and 91.6%, respectively. For patients with low- and intermediate-risk disease, the 5-year BBFS rates were 92.1% and 90.8%, respectively. In univariate and multivariate analyses, only Gleason score (<7 vs. 7; p =  0.030 vs. p < 0.05) was a significant predictor of biochemical failure. The overall rate of late and acute Grade 2 or higher genitourinary toxicity was 12.6% and 10.3%.

CONCLUSIONS

In this large single-center series, brachytherapy achieved excellent rates of medium-term biochemical control in both low and selected intermediate-risk localized prostate cancer in African-Caribbean patients. Brachytherapy seems to be an excellent choice of treatment, with excellent outcomes and limited morbidity for African-Caribbean populations.

African-american race is a predictor of seminal vesicle invasion after radical prostatectomy

INTRODUCTION

The purpose of the study was to determine whether racial differences exist in the pattern of local disease progression among men treated with radical prostatectomy (RP) for localized prostate cancer (PCa), which is currently unknown. In this study we evaluated the pattern of adverse pathologic features in an identical cohort of African-American (AA) and Caucasian (CS) men with PCa.

PATIENTS AND METHODS

The overall cohort consisted of 1104 men (224 AA, and 880 CS) who underwent RP between 1990 and 2012. We compared preoperative factors and pathologic outcomes after RP across race groups. Multivariate analysis was used to identify factors predictive of adverse pathologic outcomes. The effect of race on adverse pathologic outcomes and biochemical control rate (BCR) was evaluated using multivariate regression model and Kaplan-Meier analysis.

RESULTS

The 10-year BCR was 59% versus 82% in AA and CS men, respectively (P = .003). There was no significant difference in extraprostatic spread (P = .14), positive surgical margin (P = .81), lymph node involvement (P = .71), or adverse pathologic features (P = .16) across race groups. However, among patients with ≥ 1 adverse pathologic features, AA men had higher rate of seminal vesicle invasion (SVI) compared with CS men (51% vs. 30%; P = .01). After adjusting for known predictors of adverse pathologic features AA race remained a predictor of SVI.

CONCLUSION

AA men have an increased risk of SVI after RP, particularly among men with Gleason ≤ 6 disease. This might represent racial differences in the biology of PCa disease progression, which contribute to poorer outcomes in AA men.

Early results of prostate cancer radiation therapy: an analysis with emphasis on research strategies to improve treatment delivery and outcomes

BACKGROUND

There is scant data regarding disease presentation and treatment response among black men living in Africa. In this study we evaluate disease presentation and early clinical outcomes among Ghanaian men with prostate cancer treated with external beam radiotherapy (EBRT).

METHODS

A total of 379 men with prostate cancer were referred to the National Center for Radiotherapy, Ghana from 2003 to 2009. Data were collected regarding patient-and tumor-related factors such as age, prostate specific antigen (PSA), Gleason score (GS), clinical stage (T), and use of androgen deprivation therapy (ADT). For patients who received EBRT, freedom from biochemical failure (FFbF) was evaluated using the Kaplan-Meier method.

RESULTS

Of 379 patients referred for treatment 69.6% had initial PSA (iPSA) > 20 ng/ml, and median iPSA was 39.0 ng/ml. A total of 128 men, representing 33.8% of the overall cohort, were diagnosed with metastatic disease at time of referral. Among patients with at least 2 years of follow-up after EBRT treatment (n=52; median follow-up time: 38.9 months), 3- and 5-year actuarial FFbF was 73.8% and 65.1% respectively. There was significant association between higher iPSA and GS (8-10 vs. ≤7, p < 0.001), and T stage (T3/4 vs. T1/2, p < 0.001).

CONCLUSIONS

This is the largest series reporting on outcomes after prostate cancer treatment in West Africa. That one-third of patients presented with metastatic disease suggests potential need for earlier detection to permit curative-intent therapy. Data from this study will aid in the strategic development of prostate cancer research roadmap in Ghana.

Impact of race on biochemical disease recurrence after prostate brachytherapy

BACKGROUND

Understanding racial differences in disease presentation and response to therapy is necessary for the effective treatment and control of prostate cancer. In this study, the authors examined the influence of race on biochemical disease-free survival (BDFS) among men who received prostate brachytherapy.

METHODS

In total, 2301 men were identified who had a minimum follow-up of 24 months and had received low-dose-rate brachytherapy for prostate cancer at the Mount Sinai Medical Center from June 1990 to October 2008. Patient factors, with specific emphasis on patient race, were analyzed with respect to freedom from biochemical failure (FFbF). Kaplan-Meier analyses, life-tables, and log-rank tests were used to identify variables that were predictive of 10-year FFbF.

RESULTS

In this series, a total of 2268 patients included 81% Caucasians, 12% African Americans, 6% Hispanics, and 1% Asians. The 10-year actuarial FFbF rate was 70% for AA men and 84% for all others (P = .002). Between Caucasian men and AA men, the 10-year FFbF rate was 83% versus 70%, respectively (P = .001).There was no significant difference in 10-year FFbF between Caucasian men and Hispanic men (83% vs 86%, respectively; P = .6). The 10-year FFbF rate for Hispanic men and AA men was 86% versus 70%, respectively (P = .062). A greater percentage of AA men presented with higher prostate-specific antigen levels (PSA) (>10 ng/mL; 44% vs 21%; P < .001) and, thus, with higher risk disease (24% vs 15%; P < .001) compared with Caucasian men. Among the men with low-risk disease, the 10-year FFbF rate was 90% for Caucasian men and 76% for AA men (P = .041). The 10-year BDFS rate for patients who received brachytherapy alone was 86% for Caucasian men and 61% for AA men (P = .001); however, this difference was not observed when brachytherapy was combined with androgen-deprivation therapy(ADT) with or without supplemental external-beam radiotherapy (EBRT). Multivariate analysis revealed that PSA (P = .024), Gleason score (P < .001), the biologic effective dose (P < .001), EBRT (P = .002), ADT (P = .03), and AA race (P = .037) were significant predictors of 10-year FFbF. No significant differences was observed in overall survival, cause-specific survival, or distant metastasis-free survival between racial groups.

CONCLUSIONS

AA race appeared to be an independent negative predictor of BDFS after prostate brachytherapy, and this result may highlight the need for more aggressive therapy in this patient population.

Analysis of impact of age and race on biochemical control after radiotherapy in different prostate cancer settings

OBJECTIVES

To provide a single-institution analysis of the impact of age and race on biochemical control after radiotherapy (RT) administered in different prostate cancer scenarios. Age and race are among the most controversial prognostic factors in determining outcome after RT. Proper understanding of these prognostic factors can assist in both treatment decision-making and the general understanding of the natural history of prostate cancer.

METHODS

The records of 527 consecutive nonmetastatic patients undergoing RT at a single institution and for whom demographic, disease, treatment, and follow-up information were available were reviewed. The cohort was divided into two categories: locally advanced/localized (458 patients) and postprostatectomy (69 patients). Biochemical failure-free survival (BFFS) curves were compared within each group to determine the influence of age and race on biochemical control.

RESULTS

BFFS curves for the entire study population did not reveal any statistically significant difference when separated by age (younger than 60 years versus 60 to 69 years versus 70 years or older; 4-year BFFS 75% versus 70% versus 72%, respectively; P = 0.773) or by race (African American versus white; 4-year BFFS 74% versus 70%, respectively; P = 0.469). Additionally, no statistically significant differences were observed as a function of stage or age within either category (intact prostate or postprostatectomy).

CONCLUSIONS

Age and race did not, in our study, independently influence biochemical control after RT for nonmetastatic prostate cancer. On the basis of the results of this study, age and race should not be used as independent factors in treatment decision-making and in patient counseling concerning prostate cancer.

Racial differences in prostate cancer treatment outcomes: a systematic review

Although differences in prostate cancer incidence and mortality between black and white men are widely accepted, the existence of racial differences in treatment outcomes remains controversial. We conducted a systematic review of racial differences in prostate cancer treatment outcomes. Systematic review of literature from 1992-2002 was conducted. Database searches were performed using the terms: "prostate cancer" (keyword) or "prostate neoplasm" (subject heading) + "blacks" (subject heading) or "blacks" (keyword) + "African-Americans" (subject heading or "African-Americans" (keyword). Two hundred fifty-eight relevant articles were identified; 29 fit the inclusion criteria. All but 3 were retrospective. Seven (24%) studies were conducted at Veterans Affairs medical centers. Treatment included radical prostatectomy (15 studies), hormonal therapy (5 studies), and radiotherapy (12 studies). Three studies included more than 1 treatment. Twenty-three (79%) studies, observed no significant difference in treatment outcomes between races. The remainder found worse outcomes among black men, including worse 5-year survival (HR range, 2.35-96.74) and higher rates of PSA failure (OR range, 1.15-1.69). Most studies investigating racial differences in prostate cancer treatment outcomes over the past 10 years found no difference between races after controlling for tumor and patient characteristics. Efforts to narrow the gap between black and white prostate cancer mortality should focus on ensuring that all patients receive optimal treatment and that all patients become informed about the use of screening for early cancer detection. Research should focus on interventions to reduce advanced presentation of the disease and disease-related mortality among black men.

Efficacy of brachytherapy for prostate cancer in African Americans compared with Caucasians

PURPOSE

To compare the biochemical response to prostate brachytherapy between African Americans and Caucasians in a consecutive series of patients treated at a single institution.

METHODS AND MATERIALS

Between July 1995 and October 2001, 173 patients were treated with permanent (125)I seed implantation alone for presumed localized adenocarcinoma of the prostate. Twelve patients were African American and their biochemical response to treatment was compared with the 161 Caucasian patients. The patients were evaluated for biochemical recurrence according to the ASTRO consensus statement and for achieving and maintaining PSA nadirs of < or = 1.0, < or = 0.5, and < or = 0.2. Median pretreatment PSA level was 8 for the African American group and 6 for the Caucasian group. Median Gleason score for each group was 6 and no patients had palpable extraprostatic disease at the time of treatment.

RESULTS

None of the African American patients have experienced biochemical recurrence compared with 7.5% of the Caucasian patients (p=0.34). The percentage of African American patients achieving and maintaining a PSA level of < or = 1.0 was 83% compared with 89% for the Caucasian patients (p=0.61). PSA nadir of < or = 0.5 was achieved in 75% of the African American patients and 81% of the Caucasian patients (p=0.52) and 50% of the African American patients experienced PSA levels of < or = 0.2 compared with 59% of the Caucasian patients (p=0.88).

CONCLUSION

African American patients with prostate cancer have in general been reported to have worse prognosis compared with Caucasians. This series suggests similar outcome between African American and Caucasian patients treated with brachytherapy for prostate cancer.

Clinical features and treatment outcome of Hispanic men with prostate cancer following external beam radiotherapy

PURPOSE

We retrospectively analyzed the clinical characteristics and outcomes of Hispanic men compared with other groups who underwent radiotherapy alone for localized or locally advanced prostate cancer.

MATERIALS AND METHODS

Between April 1987 and January 1998, 964 men who underwent full dose external beam radiotherapy alone for localized or locally advanced prostate cancer were included in the study. Patient medical records were reviewed for pertinent information.

RESULTS

Of the 964 men 810 were non-Hispanic white, 54 were Hispanic and 86 were black Americans. The most significant difference among the groups was in the proportion of patients who presented with initial prostate specific antigen (PSA) greater than 20 ng/ml (22% of Hispanic vs 11% of white men, p = 0.0012). In addition, 17% of Hispanic men had a Gleason score of 8 or greater compared with 11% of white men (p = 0.0265). A greater proportion of Hispanic patients also had a less favorable posttreatment PSA nadir of greater than 1 ng/ml compared with white patients, (44% vs 26%, p = 0.0214), which may have translated into a trend toward a lower 5-year disease-free survival rate in Hispanics vs white men (52% vs 65%, p = 0.07).

CONCLUSIONS

Hispanic men presented with higher PSA and higher grade prostate cancer than white men. Furthermore, a higher percent of Hispanic men had a PSA nadir of 1 ng/ml or greater after radiotherapy, which may have been responsible for their trend toward a decreased 5-year disease-free survival rate compared with white men. Improved screening and early detection may improve disease-free survival in Hispanic men with localized prostate cancer.

Race independently predicts prostate specific antigen testing frequency following a prostate carcinoma diagnosis

BACKGROUND

The goals of the current study were to describe patterns of prostate specific antigen (PSA) surveillance for prostate carcinoma progression in a community-based cohort of patients and to identify independent clinical and sociodemographic factors that predict the frequency of surveillance.

METHODS

Patients diagnosed with localized prostate carcinoma from October 1, 1991 to December 31, 1992 in New Haven and Hartford, Connecticut, were identified. Data were collected through standardized outpatient medical record review. Multivariate statistical methods were used to determine the factors that independently predicted the frequency of surveillance.

RESULTS

Six hundred fifty-eight men with localized prostate carcinoma were included in the cohort. Forty-five percent of all patients were tested at least once annually, and 69% were tested at least once every 2 years. Multivariate models indicated that African American men were half as likely as Caucasian men to receive annual testing (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24-0.97). Men diagnosed at age 70 years or older were 38% less likely to have annual testing than men diagnosed between the ages of 65 and 69 (OR, 0.62; 95% CI, 0.41-0.94). A higher Gleason score and PSA at presentation also were associated independently with higher rates of annual PSA surveillance.

CONCLUSIONS

Postdiagnosis PSA surveillance is common, although not universal. African American men were at significantly greater risk for receiving less frequent testing compared with Caucasian men. This disparity in access to care may explain, in part, previously observed racial differences in survival in prostate carcinoma. Further research is needed to identify the reasons for the racial disparity in PSA surveillance and to design interventions to lessen these differences.

Effect of race on biochemical disease-free outcome in patients with prostate cancer treated with definitive radiation therapy in an equal-access health care system: radiation oncology report of the Department of Defense Center for Prostate Disease Research

PURPOSE

To report on the first collaboration of the Department of Defense Center for Prostate Disease Research concerned with the relationship between African American race and biochemical disease-free outcomes after definitive radiation therapy.

MATERIALS AND METHODS

Information from the medical records of 1,806 patients (1,349 white, 343 African American, 42 of "other" races, and 72 of "unknown" races) treated with definitive radiation therapy between 1973 and 2000 was reviewed. Patients receiving adjuvant hormonal therapy or postoperative adjuvant or salvage radiation therapy were excluded. Biochemical failure was calculated in over 96% of cases by using ASTRO criteria; patients with fewer than three follow-up visits were considered to have biochemical failure with a prostate-specific antigen (PSA) value more than 10-fold the previous value or with any value greater than 50.0 ng/mL. Median radiation therapy doses were similar. The median follow-up was 58.4 months. Kaplan-Meier tests, Cox proportional hazards regression analysis, and log-rank tests were used for data analysis.

RESULTS

There was no statistically significant difference in biochemical disease-free survival according to race when patients were stratified according to T stage. African American race conferred a negative prognosis for patients with lesions of Gleason biopsy score 7 (P =.004) but not for patients with lesions of Gleason score 2-4 (P =.14), 5-6 (P =.79), or 8-10 (P =.86). Similarly, African American race conferred a negative prognosis in patients with PSA values of 20.1-50.0 ng/mL (P =.01) at presentation but not in patients with PSA values less than or equal to 4.0 ng/mL (P =.84), 4.1-10.0 ng/mL (P =.71), 10.1-20.0 ng/mL (P =.75), or above 50.0 ng/mL (P =.15) at presentation. At multivariate analysis, race was not a statistically significant predictor of outcome.

CONCLUSION

In the equal-access health care system of the Department of Defense, African American race is not associated with a consistently negative prognosis in patients treated with definitive radiation therapy for prostate cancer. Race appears to confer a negative prognosis only in patients with advanced disease at presentation.

The Patterns of Care Survey of radiation therapy in localized prostate cancer: similarities between the practice nationally and in minority-rich areas

PURPOSE

Over the last two decades, the chance for the cure of localized prostate cancer by radiation has been improved by the widespread use of PSA for early detection and by a number of technical advances in treatment delivery. This study was designed to determine whether the stage of presentation and the quality of radiation treatment delivered are comparable between Caucasian and minority patients nationally and within minority-rich areas.

METHODS AND MATERIALS

A random survey conducted for the Patterns of Care Study in Radiation Oncology of 80 facilities treating patients with radiation in the USA. Of these, 67 comprise the "National Survey" and 13 a "Minority-Rich" survey (>40% of treated patients are minorities). Nine hundred twenty-six men with localized prostate cancer were treated in 1994. Five hundred ninety-five were in the national and 331 in the minority-rich survey. The main outcome measures were the clinical features of Caucasian and minority men at presentation and technical characteristics of the treatment delivered to them.

RESULTS

African-American men presented with more advanced disease (higher-presenting PSA and T-stage) than Caucasians in both the national and the minority-rich surveys. Hispanics also presented with later disease and could be grouped with African-American men rather than Caucasians. Overall the stage and PSA at presentation was earlier than seen in the previous Patterns of Care Study survey of 1989. The quality of treatment delivered has improved since 1989, with no distinction seen between those facilities sampled nationally and those within minority-rich areas.

CONCLUSION

African-American and Hispanic men with prostate cancer present for therapy at a later stage than Caucasian men, but when they do, the treatment received is of comparable quality.

Equivalent racial outcome after conformal radiotherapy for prostate cancer: a single departmental experience

PURPOSE

African-American (AA) men with prostate cancer present with advanced disease, relative to white (W) men. This report summarizes our clinical and biochemical control (bNED) rates after conformal radiotherapy (RT). In particular, we aim to characterize any race-based outcome differences seen after comparable treatment.

PATIENTS AND METHODS

We reviewed 893 patients (418 AA and 475 W) with clinically localized prostate cancer treated between 1988 and 1997. Neoadjuvant hormonal blockade was used in 22.5% of cases, and all patients received conformal RT to a median dose of 68 Gy (range, 60 to 74.8 Gy). Biochemical failure was defined according to the American Society of Therapeutic Radiology and Oncology consensus definition. Median follow-up was 24 months (range, 1 to 114 months).

RESULTS

The 5-year actuarial survival, disease-free survival, and bNED rates for the entire population were 80.5%, 70.0%, and 57.6%, respectively. When classified by prognostic risk category, the 5-year actuarial bNED rates were 78.7% for favorable, 57.7% for intermediate, and 39.8% for unfavorable category patients. AA men presented at younger ages and with more advanced disease. Controlled for prognostic risk category, AA and W men had similar 5-year actuarial bNED rates in favorable (78% v 79%, P: = .91), intermediate (52% v 62%, P: =.44), and unfavorable categories (36% v 45%, P: = .09). Race was not an independent prognostic factor (P: = .36).

CONCLUSION

Conformal RT is equally effective for AA and W patients. More research is needed in order to understand and correct the advanced presentations in AA men. These data suggest a need for early screening in AA populations.

Comparison of clinical outcome in black and white women treated with radiotherapy for cervical carcinoma

BACKGROUND

The purpose of this investigation was to evaluate the significance of race on the cancer-specific survival outcome of women treated with radiotherapy for advanced-stage cancer of the uterine cervix.

METHODS

Data from 922 women with cancer of the uterine cervix treated with radiotherapy were reviewed. Patients were treated at the Mallinckrodt Institute of Radiology from 1959 through 1993. There were 576 women with clinical Stage II cancer and 346 women with clinical Stage III cancer. All women were treated following standard medical care treatment policies according to the stage of their disease. Data were analyzed by race and known treatment-related prognostic factors. Overall and cancer-specific survivals were evaluated.

RESULTS

The 5-year cancer-specific survivals for clinical Stage II were 66 and 61% (P = 0.56) for white and black women, respectively. The corresponding 5-year overall survivals were 60 and 51% (P = 0.02). The 5-year cancer-specific survivals for clinical Stage III were 38 and 47% (P = 0.34) for white and black women, respectively. The associated 5-year overall survivals were 32 and 40% (P = 0.37). No differences in treatment-related factors were identified.

CONCLUSIONS

In a cancer treatment system where black and white women with clinical Stage II and III cancer of the uterine cervix are all treated with radiotherapy alone, following standard treatment policies, no significant difference in cancer-specific survival outcome is shown. Multivariate analysis revealed that clinical stage and overall treatment time are significant variables affecting the control of tumor by radiotherapy. Overall survivals for the two racial groups are different and may be related to other non-cancer-related factors.

Race is not an independent predictor of biochemical recurrence after radical prostatectomy in an equal access medical center

OBJECTIVES

To compare the racial differences in clinical and pathologic features between black and white men who underwent radical prostatectomy (RP) in an equal access health care center and to determine whether race is an independent predictor of biochemical recurrence.

METHODS

A retrospective survey of 273 patients (125 black, 148 white) who underwent RP at the West Los Angeles Veterans Affairs Medical Center between 1991 and 1999 was undertaken. Patients were analyzed for racial differences in age at diagnosis, clinical stage, preoperative serum prostate-specific antigen (PSA), and Gleason score of the prostate biopsy specimens. Surgical specimens were studied to determine pathologic stage, Gleason score, incidence of seminal vesicle invasion, positive surgical margins, capsular penetration, and pelvic lymph node involvement. Patients were followed for PSA recurrence (greater than 0.2 ng/mL). Multivariate analysis was used to determine the clinical and pathologic variables that were significant in predicting biochemical recurrence after RP and to determine whether race was an independent predictor of biochemical failure.

RESULTS

No significant differences were found between black and white men in the preoperative factors (clinical stage, age at diagnosis, biopsy Gleason score, and serum PSA) or in the pathologic features of the RP specimens (Gleason score, pathologic stage, incidence of positive surgical margins, capsular penetration, seminal vesicle invasion, or lymph node involvement). In addition, no differences were found between black and white men in the PSA recurrence rates after RP using Kaplan-Meier survival curves (P = 0.651). Multivariate analysis revealed that serum PSA (P = 0.010), biopsy Gleason score (P = 0. 003), younger age (P = 0.010), surgical Gleason score (P = 0.005), and lymph node involvement (P = 0.022) were all independent predictors of biochemical recurrence. Race was not a significant predictor of biochemical failure in multivariate analysis (P = 0. 199).

CONCLUSIONS

In an equal access medical care facility, no differences were evident between black and white men in the preoperative clinical factors or the pathologic features of the RP specimens. In addition, no differences were observed in the PSA recurrence rates after RP. Serum PSA, biopsy Gleason score, younger age, surgical Gleason score, and lymph node involvement were all independent predictors of biochemical recurrence. Race was not an independent predictor of biochemical recurrence.

Screening for prostate cancer in African Americans

African American men are known to have a higher risk of developing prostate cancer. Historically, African American men have presented at a higher stage and had a worse outcome from the disease than non-African American men. There is an ongoing debate whether this disparity is due to biologic, environmental, or behavioral factors, or a combination of these factors. Furthermore, lack of access to care is implicated. Despite this debate, there is emerging data that African American men and their families are receptive to education and early detection. Encouraging data from the military, Veteran's Administration, and private sector suggest that African American men can have a similar outcome to non-African American men if diagnosed early and treated effectively. Early detection efforts depend on prostate-specific antigen (PSA) testing. This article discusses various options for using the PSA test to more effectively screen African American men. In general, testing starting at age 40 is recommended using an upper limit of normal for PSA at 2.0 to 2.5 ng/mL for men between 40 and 49 years of age. In older men, maintaining this lower PSA threshold is reasonable to optimize curable cancer; however, published guidelines of 0 to 4.0, 0 to 4.5, and 0 to 5.5 ng/mL in African American men in their 50s, 60s, and 70s, respectively, are also recognized to balance the sensitivity and specificity of testing. Population-based prospective clinical trials of African American men are needed to further fine-tune the use of PSA in early detection, and to assess whether screening will improve the disease-specific mortality of prostate cancer in the population.

The impact of race on biochemical disease-free survival in early-stage prostate cancer patients treated with surgery or radiation therapy

PURPOSE

To assess the impact of race on biochemical freedom from recurrence in patients with early-stage prostate cancer treated either by radical prostatectomy or radiation therapy.

METHODS

Between July 1989 and December 1994, 693 patients with early-stage prostate cancer were treated with radiation (302 patients) or by radical prostatectomy (391 patients) at Barbara Ann Karmanos Cancer Institute/Wayne State University. Stage, Gleason score, race, pretreatment PSA, and follow-up PSA values were abstracted. There were 387 Caucasian males (CM) and 306 African-American males (AAM). None of the patients received hormone therapy. Radiation therapy was delivered using photon irradiation (249 patients, median dose 69 Gy) or mixed neutron/photon irradiation (53 patients, median dose 10 NGy + 38 PGy). Median follow-up was 36 months (range 2-70) for CM and 35 months (range 1-70) for AAM.

RESULTS

Thirty-seven percent of patients treated surgically were AAM, compared to 53% in the radiation group (p = 0001). AAM had a higher median prostate-specific antigen (PSA) than CM (9.78 ng/ml vs. 8.0 ng/ml, p = 0.01). Thirty-three percent of AAM had a pretreatment PSA greater than 15 ng/ml compared to 20% of CM (p = 0.00001). Disease-free survival (DFS) by race was equivalent at 36 months, 81% for CM and 77% for AAM (p = NS). For patients with PSA < or =15, DFS rates were 87% and 85% for CM and AAM, respectively. DFS rates for patients with PSA >15 were 61% for CM and 64% for AAM (p = NS). Significant prognostic factors on multivariate analysis included pretreatment PSA (p = 0.0001) and Gleason score (p = 0.0001).

CONCLUSION

Race does not appear to adversely affect biochemical disease-free survival in males treated for early-stage prostate cancer. African-American males with early-stage prostate cancer should expect similar biochemical disease-free survival rates to those seen in Caucasian males.

Does race influence survival for esophageal cancer patients treated on the radiation and chemotherapy arm of RTOG #85-01?

PURPOSE

In reported retrospective non-randomized trials of treatment of esophageal carcinoma, blacks have a lower survival from esophageal cancer than whites. None of these studies has accounted for the extent of disease, or the methods and quality of treatment. We reviewed the data that included only patients treated on the chemoradiation arm of the RTOG-8501 esophageal carcinoma trial to see if there were differences in overall survival between black and white patients receiving the same standard of care.

METHODS AND MATERIALS

One hundred-nineteen patients, 37 blacks and 82 whites were evaluated who met the criteria for receiving chemoradiation of 5000 cGy and four courses of Cisplatin (75 mg/m2) and Fluorouracil (1000 mg/m2 for 4 days).

RESULTS

Blacks had squamous histology only, with 86% of blacks having weight loss of 10 lbs. or more compared to 56% of whites (p = 0.001). In addition, blacks had larger tumors and more difficulty eating (p = 0.010). Overall, there was no difference in the Kaplan-Meier median survival estimate by race (p = 0.2757). Only when we limited the analysis to the "squamous histology" subgroup, stratified according to age >70 vs. <70 years (p = 0.0002), and nodal status (p = 0.0177) in a Cox regression model analysis, did race appear to be a significant factor (p = 0.0012). However, using the entire database, the age effect was found to be a "bimodal" effect, wherein the "youngest" (< age 60 years) and "oldest" patients (age > 70 years) did poorly. Because of the dramatic differences in the age and histology distributions between blacks and whites, this issue could not be resolved in the subset of squamous only who received chemoradiation.

CONCLUSIONS

The increasing incidence of adenocarcinoma among white patients without a corresponding increase of this histology in blacks reflects a difference in diet and or lifestyle compared to blacks that deserves additional study. When treated aggressively with chemoradiation, race did not appear to be a statistically significant factor for overall survival.

Prostate-specific antigen to predict outcome of external beam radiation for prostate cancer: Walter Reed Army Medical Center experience, 1988-1995

OBJECTIVES

To assess the ability of pretreatment and post-treatment prostate-specific antigen (PSA) measurements, clinical tumor stage, tumor grade, Gleason sum, race, age, and radiation dose to predict the recurrence of prostate cancer following external beam radiation therapy (XRT) since the introduction of PSA as a tumor marker at one tertiary care center.

METHODS

The recurrence of prostate cancer among 371 evaluable patients of 389 patients treated with XRT at Walter Reed Army Medical Center was analyzed using Kaplan-Meier survival methodology and Cox multivariable regression models. Serologic (PSA) recurrence was determined using three consecutive rises in PSA after a nadir value. Clinical recurrence was defined as local recurrence (palpable or positive biopsy) and/or distant (radiographically evident) recurrence. Mean and median follow-up is 40.2 and 39.4 months, respectively (range 3.0 to 89.5), and minimum follow-up is 18 months for patients who were alive at the time of analysis. No patient received adjuvant hormonal therapy. Potential prognostic factors evaluated are pretreatment PSA, PSA nadir, age, race, clinical tumor stage, tumor grade, Gleason sum, and radiation dose.

RESULTS

Of the 371 evaluable patients, 125 had disease recurrence. The Kaplan-Meier 5-year disease-free survival (DFS) rates for significant pretreatment variables in univariate analyses are as follows: pretreatment PSA less than 4 (79%), 4.1 to 10 (67%), 10.1 to 20 (57%), 20.1 to 50 (27%), and more than 50 (0%); for clinical tumor Stage T1a-T1c (84%), T2a-T2c (51 %), and T3-T4 (29%); for tumor grade well (58%), moderate (58%), and poor (30%). Four-year DFS rates for Gleason sum are 2 to 4 (82%), 5 (72%), 6 (56%), and 7 to 10 (48%). In multivariable Cox regression analysis with backward elimination of nonsignificant variables, age, race, tumor grade, and radiation dose were eliminated, leaving pretreatment PSA, clinical tumor stage, and Gleason sum as significant prognostic factors. Analysis of a Cox model that included nadir PSA as a time-dependent variable showed it to be the strongest prognostic factor variable in the analysis.

CONCLUSIONS

XRT remains a suitable treatment modality for patients with pretreatment PSA less than 20.0, clinical tumor Stages T1-T2, and Gleason sum 2 to 6 prostate cancer. Patients achieving a nadir value less than 0.5 have more durable treatment outcomes.

Prostate cancer in African-American men: outcome following radiation therapy with or without adjuvant androgen ablation

PURPOSE

To compare the outcome of irradiated clinically localized prostate cancer in African-American and white patients.

METHODS AND MATERIALS

This was a retrospective review of 1,201 men, 116 African-American and 1,085 white, with T1-T3, N0/NX, M0 prostate cancer receiving external radiation between 1987 and 1996. Pretreatment characteristics, treatment parameters, and outcome (relapse or rising prostate-specific antigen [PSA] levels, local recurrence, metastatic relapse, and survival) were compared between the groups using univariate and multivariate statistical methods.

RESULTS

There were no significant differences between African-American and white patients in T-stage, Gleason score, prostatic acid phosphatase (PAP) level, and testosterone level. African-Americans had a significantly lower incidence of abnormal digital rectal findings and a proportionally higher incidence of obstructive urinary symptoms at presentation and tended to be somewhat younger. A major difference between the two groups was in the significantly higher PSA levels among African-Americans (median, 14 ng/ml) than among white patients (median, 9.5 ng/ml). This translated into a higher incidence of unfavorable disease according to our criteria (39% vs. 25%) among African-Americans and, thus, to the more frequent use of adjuvant androgen ablation and to somewhat higher radiation doses in these patients. With a median follow-up of 42 months the overall 6-year freedom from relapse for African-Americans was 63% compared to 61% for whites (p = 0.634). We found no significant differences in biochemical relapse rates between any subgroups of African-Americans and whites. Specifically, even patients who did not have androgen ablation, when stratified by PSA levels, had similar outcomes regardless of race. Likewise, local recurrence and metastasis rates were not significantly different between the two groups.

CONCLUSIONS

Although African-American patients tend to have higher pretreatment PSA levels than white patients, the outcome for the disease is similar in the two groups when stratified by known pretreatment prognostic factors. Our data provide no evidence for the hypothesis that prostate cancer in African-Americans is intrinsically more virulent than in whites.

Racial variation in cancer care: a case study of prostate cancer

Prostate cancer is one of several cancers that affects U.S. racial and ethnic groups differently with Blacks experiencing a higher incidence and mortality rate than Whites. Observational studies indicate that black patients with prostate cancer are less likely to receive definitive therapy. This pattern of care appears to be attributable primarily to the later clinical stage of disease at presentation; socioeconomic considerations as such relate to access to care (e.g., ability to pay) appear to play a lesser role. Other patient related factors, for example, preferences for certain therapies, have not been well studied; consequently, their ability to explain racial variations in use of therapies for this disease is unclear. Potential areas for future research should focus on the reasons for the detection of the disease at a later clinical stage and, hence, with worse prognosis.

Predicting the outcome of radiotherapy for prostate carcinoma: a model-building strategy

BACKGROUND

Clinical research of prostate carcinoma could be enhanced by models that allow early and reliable prediction of outcome. In this study, the authors describe a model-building strategy and compare different models.

METHODS

The sample population was comprised of 158 patients treated definitively with radiotherapy. Univariate and multivariate logistic regression analyses were conducted to identify prognostic factors and select the best predictive model. Variables included age, race, method of diagnosis (needle biopsy vs. transurethral resection of the prostate), stage, grade, pretreatment prostate specific antigen (PSA), in-treatment PSA (PSA(tx)), posttreatment PSA (PSA(post)), and nadir PSA. The following indices were used to compare discriminatory power: log-likelihood function, Akaike information criterion, the generalized coefficient of determination, and the area under the receiver operating characteristic curve.

RESULTS

At last follow-up, 49 patients (31%) had recurrence of carcinoma. By univariate analysis, the failure rate was significantly higher in patients with advanced stage, higher grade, higher pretherapy PSA, and nadir PSA > 1 ng/mL (P < 0.0001). Pretherapy PSA was associated significantly with stage, age, and nadir PSA (P = 0.001, P = 0.001, and P = 0.001, respectively). All PSA measurements were significantly interrelated. Nadir PSA was the most predictive variable. Significant gains (P = 0.01) in predictive power were derived from inclusion of PSA(tx), but not PSA (post). Age, race, stage, grade, and method of diagnosis contributed predictive power in addition to that derived from PSA levels (P = 0.01, log-likelihood test). The authors' model of choice predicts outcome with an overall correctness, sensitivity, specificity, and false-negative rate of 81.8%, 87.2%, 79.6%, and 12.8%, respectively.

CONCLUSIONS

Applying the strategy described, a model was selected that allowed accurate prediction of failure shortly after the completion of therapy.

Racial differences in operating characteristics of prostate cancer screening tests

PURPOSE

We evaluated racial differences in the operating characteristics of prostate specific antigen (PSA) and digital rectal examination as screening tests for early detection of prostate cancer.

MATERIALS AND METHODS

We screened 18,527 white and 949 black men 50 years old or older using serum PSA measurement and digital rectal examination. We recommended biopsies if either test was suspicious for cancer. For PSA greater than 4.0 ng./ml. and rectal examination we calculated relative sensitivity (percentage of men with cancer who had a positive test), specificity (percentage of men without cancer who had a negative test) and positive predictive value (percentage of men with a positive test in whom cancer was detected) for the prediction of prostate cancer stratified by race.

RESULTS

In white and black men PSA greater than 4.0 ng./ml. detected more cancers than rectal examination (p < 0.002) with a trend for a greater increase in sensitivity in black men. PSA was associated with fewer false-positives than rectal examination in white (p < 0.0001) but not in black (p > 0.05) men. Positive predictive value for prostate cancer of PSA and rectal examination was greater in black than in white men (48 versus 34 and 38 versus 22%, respectively).

CONCLUSIONS

PSA detects more cancers than rectal examination in both races, although this advantage is more pronounced in black men. In white men PSA yielded fewer false-positive results than rectal examination. However, PSA had more false-positive results than rectal examination in black men. Cancer was detected in a higher percentage of black men with PSA greater than 4.0 ng./ml. and, therefore, the risk of cancer associated with PSA greater than 4.0 ng./ml. differs by race. In a screening setting the widely accepted 25 to 30% positive predictive value for PSA greater than 4.0 ng./ml. may only apply to white men. A higher risk estimate of 36 to 60% is more accurate in black men.

Diagnostic and prognostic markers for human prostate cancer

BACKGROUND

The incidence and mortality of prostate cancer are increasing at alarming rates, partially due to an aging population. Early detection of prostate cancer, using clinically sensitive procedures and/or tumor markers (e.g., prostate-specific antigen [PSA]), is of prime importance. However, the choice of therapeutic interventions for prostate cancer at the time of diagnosis is largely dependent on clinical and pathologic staging and prediction of the degree of aggressiveness of the disease. Clinically applicable prognostic markers are urgently needed to assist in the selection of optimal therapy.

METHODS

Literature review of the potential diagnostic and prognostic markers for human prostate cancer.

RESULTS

Well-established tissue prognostic indicators, including histologic grade, margin positivity, pathologic stage, intraglandular tumor extent, and DNA ploidy, are not reviewed in this paper. Recently, a number of novel markers have been identified. In this paper, we begin with a discussion of a number of well-established as well as investigational diagnostic markers and then focus on evaluation of prognostic markers. Diagnostic markers that have prognostic value and investigational prognostic markers are also discussed.

CONCLUSIONS

Currently, only PSA is utilized for early diagnosis and monitoring of prostate cancer. A number of potential prognostic markers warrant further investigation. Multimarker analysis is implicated.

Nonrandomized evaluation of pelvic lymph node irradiation in localized carcinoma of the prostate

PURPOSE

A great deal of controversy exists regarding the potential benefit of pelvic lymph node irradiation compared with treatment to the prostate only in patients with localized prostate cancer. Despite numerous reports, including a randomized study, this issue has not been completely elucidated.

METHODS AND MATERIALS

A total of 963 patients with histologically proven localized adenocarcinoma of the prostate treated with definitive radiation therapy alone were analyzed. Median follow-up was 6.5 years (minimum: 2 years, maximum: 22 years). Pelvic lymph nodes received 40 to 55 Gy with anteroposterior/posteroanterior and sometimes lateral stationary portals in 1.8 Gy daily fractions; an additional dose was delivered to the prostate with 120 degrees bilateral are rotation to complete doses of 65 to 68 Gy for Stage A2 and B tumors and 68 to 71 Gy for Stage C tumors. The same total doses were delivered with smaller fields when the prostate only was treated.

RESULTS

In Stage A2 (T1b,c) the 10-year clinical pelvic failure rate was 16% regardless of the volume irradiated or tumor differentiation. With Stage B (T2) well- or moderately differentiated tumors, the 10-year pelvic failure rates were 22% when pelvic lymph nodes were irradiated and 32% when prostate only was irradiated (p = 0.41). With Stage A2 (T1b,c) and B (T2) poorly differentiated tumors, the 10-year pelvic failure rates were 32% and 7%, respectively (p = 0.72). With clinical stage C (T3) well-differentiated tumors treated with 50 to 55 Gy to pelvic lymph nodes, the pelvic failure rate was 22% compared with 37% in those receiving 40 to 45 Gy (p < or = 0.07). A significant reduction in pelvic failures was noted with Stage C poorly differentiated tumors when the pelvic lymph nodes received doses higher than 50 Gy (23%) compared with lower doses (46%) (p < or = 0.01). Volume or doses of irradiation did not influence incidence of distant metastases in any stage or tumor differentiation group. Disease-free survival did not correlate with volume treated in any clinical stage or tumor differentiation group. In 317 patients on whom pretreatment prostate-specific antigen levels were available, there is a suggestion that those treated to the pelvic lymph nodes had a higher chemical disease-free survival than those receiving prostate irradiation only. Follow-up is short, and differences are not statistically significant in any of the groups. Morbidity of therapy was slightly higher in patients treated to the pelvic lymph nodes, but in Stages A2 (T1b,c) and B (T2) differences are not statistically significant (4 to 6%). Stage C patients treated to the pelvic lymph nodes with 50 Gy had a 12% incidence of Grade 2 rectosigmoid morbidity compared with 6% in those treated with 40 Gy (p = 0.26).

CONCLUSIONS

In this retrospective analysis, pelvic lymph node irradiation did not influence local/pelvic tumor control, incidence of distant metastases, or disease-free survival in patients with clinical Stage A2 (T1b,c) or B (T2) localized carcinoma of the prostate. In patients with Stage C (T3) disease, irradiation of the pelvic lymph nodes with doses of 50 to 55 Gy resulted in a lower incidence of pelvic recurrences and improved disease-free survival. Morbidity of therapy was acceptable, although patients with Stage C disease had a somewhat higher incidence of Grade 2 rectosigmoid morbidity. Pelvic lymph node irradiation is being elucidated in properly designed prospective, randomized protocols.

Race and prognosis of brain tumor patients entering multicenter clinical trials. A report from the Radiation Therapy Oncology Group

We investigated the possible influence of race on the survival of patients with malignant gliomas enrolled in three consecutive trials of the Radiation Therapy Oncology Group (RTOG) retrospectively using the group's statistical database. There were no statistical differences between the survival rates for black patients with glioblastoma multiforme (GBM) and those for the white patients. The limited influence of therapy on this disease may be responsible in part for this result.

Pretreatment prostate-specific antigen values in patients with prostate cancer: 1989 patterns of care study process survey

PURPOSE

A Patterns of Care Study (PCS) national survey was conducted to show the national averages for processes of radiation therapy care for prostate cancer patients in 1989. In the current study we report an analysis of pretreatment prostate-specific antigen (PSA) by stage, grade, and ethnic origin.

METHODS AND MATERIALS

Process data were collected from 672 patients treated in 1989 at 71 separate institutions. Four hundred and twenty-seven (64%) of these patients had a pretreatment PSA value recorded. Three hundred and forty-three of the 427 patients were treated with external beam irradiation alone and were selected for the current analysis. The 1992 AJCC staging system was used.

RESULTS

There was a significant increase in pretreatment PSA with increasing stage. The median values of PSA were 8.3 ngm/ml in the T1 group (n = 65), 11.2 ngm/ml in the T2 group (n = 178), and 20.9 ngm/ml in the T3 group (n = 90) (p < 0.001). Ten patients were not staged. There was a significant increase in pretreatment PSA with decreasing differentiation. The median pretreatment PSA was 9.7 ngm/ml in well-differentiated tumors (n = 109), 13.0 ngm/ml in moderately differentiated tumors (n = 163), and 22.0 ngm/ml in poorly differentiated tumors. (n = 61) (p < 0.001). Ten patients had no differentiation recorded. African Americans (24) showed a significant increase in pretreatment PSA compared to Caucasians (304). The respective medians were 23.2 ng/ml and 11.9 ng/ml (p = 0.04). They also show more poorly differentiated tumors (33% vs. 17%) and more T3 tumors (46% vs. 25%). Other minorities, although small in number (n = 9) were similar to African Americans.

CONCLUSION

Pretreatment PSA levels were established for patients treated with external beam irradiation in 1989 in the United States. They increase with stage and decreasing differentiation. African Americans and other minorities show a doubling of median values compared to Caucasians' pretreatment PSA with an increase in stage and grade. The adverse prognosis observed for African Americans is predicted by their pretreatment PSA. The cause of this PSA elevation is not known and may be related to lack of access to care or to a more aggressive biology for prostate cancer in African Americans.

Epidemiology of high grade prostatic intraepithelial neoplasia

The prevalence of high grade prostatic intraepithelial neoplasia (HGPIN), the age at which this lesion starts and the potential racial or ethnic differences in its distribution are poorly documented. HGPIN is becoming increasingly implicated as a premalignant lesion for clinically significant prostatic carcinoma (PCa) with mounting evidence linking it to carcinoma according to morphologic immunohistochemical and recent genomic studies. We describe our experience with the age and race distribution of HGPIN resulting from two study populations of African-American (AA) and Caucasian (C) males. The first component of this report describes an autopsy study aimed at determining the prevalence of latent PCa and HGPIN in AA and C men 20 years of age or older; 370 (218 AA and 152 C) consecutive step-sectioned, totally embedded prostate glands were microscopically evaluated and mapped for HGPIN and PCa. HGPIN was first identified in the third decade and increased steadily with age. Latent PCa increased steadily with age with no significant difference in the prevalence between AA and C males in any age group (3rd to 8th decades). HGPIN, on the other hand, was more prevalent in AA men with 18, 31, 69, 78 and 86% in their 4th, 5th, 6th, 7th and 8th decades harboring the lesion. The corresponding figures for C men were 14, 21, 38, 50 and 63% respectively. When HGPIN was quantitated as focal and extensive according to the degree of glandular involvement, extensive HGPIN appeared earlier in AA males under 60 years of age compared to C males cohort. The difference in age distribution appeared to follow a chronological pattern, with HGPIN in AA preceding that of C males by approximately a decade. The second component of this report describes a surgical series of 345 consecutive radical prostatectomies from patients (155 AA and 190 C) with clinically localized PCa, which were thoroughly evaluated microscopically by two urologic pathologists. Similar to the findings in the autopsy study, extensive HGPIN was more prevalent in AA men 60 years of age or younger (57% vs. 33%). In both races, the mean percentage of the gland involved by HGPIN decreased with advancing age in contrast to the mean tumor volume that increased with patient age. These findings indicating a different prevalence of HGPIN in the two racial groups may help explain the higher incidence of prostatic cancer in African-Americans.

Elevated 12-lipoxygenase mRNA expression correlates with advanced stage and poor differentiation of human prostate cancer

OBJECTIVES

Prostate cancer is the most frequently diagnosed cancer and the second leading cause of cancer death in males in the United States. The mortality is due mainly to distant metastasis. Therefore, predicting the prognosis of prostate cancer patients is an important clinical problem. Previously, we demonstrated that a 12-lipoxygenase (12-LOX) metabolite of arachidonic acid, 12(S)-hydroxyeicosatetraenoic acid, enhances the invasiveness of prostate cancer cells and that a 12-LOX-selective inhibitor [N-benzyl-N-hydroxy-5-phenylpentanamide] reduces experimental metastasis in animal model systems. In this study, we investigated the potential of 12-LOX as a predictor for the aggressiveness of prostate cancer.

METHODS

The mRNA expression level of 12-LOX in 122 matching prostate normal and cancerous tissues were measured by quantitative reverse transcription- polymerase chain reaction. Possible association between 12-LOX expression and histologic grade, pathologic and clinical stage, margin positivity, age, and race was analyzed.

RESULTS

12-LOX mRNA levels were elevated in cancer cells and the expression associated with poor differentiation and invasiveness of prostate cancer. Overall, 46 (38%) of 122 evaluable patients showed elevated levels of 12-LOX mRNA in prostate cancer tissues compared with the matching normal tissues. A statistically significantly greater number of cases were found to have an elevated level of 12-LOX among T3, high grade, and surgical margin-positive than T2, intermediate, and low grade, and surgical margin-negative prostatic adenocarcinomas.

CONCLUSIONS

Our data suggest that elevation of 12-LOX mRNA expression occurs more frequently in advanced stage, high-grade prostate cancer and that 12-LOX may serve as an indicator for progression and prognosis of prostate cancer. This enzyme also may be a novel target for the development of anti-invasive and antimetastatic agents.

Poor survival of black patients in carcinoma of the endometrium

PURPOSE

To compare the prognostic factors and survivals of black and white patients with endometrial carcinoma.

METHODS AND MATERIALS

A retrospective study was undertaken of a total of 290 patients with endometrial carcinoma who were treated similarly at the Health Science Center at Brooklyn and Kings County Hospital Center from 1975 and 1990. One hundred and thirty-six of 290 (47.2%) were black and 135/290 (46.9%) were white. Well-known prognostic factors affecting endometrial carcinoma were studied in black and white group of patients. Their overall survival and comparison of survival in each prognostic group were also estimated using multi-variate analysis.

RESULTS

Fifty-four percent of white patients had Stage I disease, compared to 45.9% in black patients. In Stage II, 51.6% were white and 48.4% were black, and in Stage III, 88.89% were black and 11.1% were white patients (p = 0.034). Fifty six percent Grade 1 patients were white and 44% were black. In Grade 2, 53.3% were white and 46.7% were black and in Grade 3 disease, 70.5% were black and 29.5% were white (p = 0.008). Up to the inner third of myometrial invasion had occurred in 60.6% of white patients and 39.4% in black patients. The middle third of the myometrium was invaded in 60.7% of white patients, and 39.3% of black patients. Thirty-seven percent of outer third of myometrial invasion was found in white patients and 63% in black patients (p = 0.038). Seventy-two percent of positive lymph nodes were found in black patients and 28.0% in white patients (p = 0.01). Sixty-one percent of patients with positive peritoneal cytology were black as compared to 38.7% in white patients (p = 0.017). The overall ten-year corrected survival for white and black patients was 72% and 40%, respectively (p = 0.0003). Survivals comparisons, when stratified by race and each prognostic group, showed statistically significant overall survival differences in favor of white patients.

CONCLUSION

Black patients with endometrial carcinoma have poor survival. Low socio-economic status (SES) would not explain these findings. More research is required to determine the cause of poor survival in black patients with endometrial carcinoma.